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Clavicle Shaft Fracture ORIF

Planning

B

Preoperative Plan

1

Radiographic templating

  • template fracture with instrumentation

2

Execute surgical walkthrough

  • describe the steps of the procedure verbally prior to the start of the case

3

Description of potential complications and steps to avoid them

C

Room Preparation

1

Surgical instrumentation

  • appropriate precontoured plate or LCP

2

Room setup and equipment

  • standard operating table
  • fluoroscopy

3

Patient positioning

  • place in the supine or modified beach chair position
  • place a bump on the medial portion of the scapula on the operative shoulder

Technique

D

Approach

1

Identify and mark the fracture

  • infiltrate area with dilute epinephrine to minimize bleeding
  • make a longitudinal incision just inferior to and in line with the clavicle

2

Identify critical structures

  • identify the supraclavicular nerves
  • these nerves cross the clavicle at the level of the platysma
  • minimize removal of muscle attachments and periosteum as much as possible
E

Fracture Reduction and Provisional Fixation

1

Reduce the fracture

  • realign the fracture with a distractor
  • use clamps and kwires to reduce comminuted fractures
F

Superior Plate Final Fixation

1

Place the superior plate

  • place a LCP or precontoured plate to the superior aspect of the clavicle

2

Prepare screw placement

  • drill the clavicle in a superior to inferior direction

3

Place screws

  • use depth gauge to measure the length of each screw
  • a minimum of three screws should be placed bicortically in each major fragment of the fracture
  • place interfragmentary screw
  • this screw greatly enhances the stability of the construct
G

Anterior Plate Final Fixation (alternative placement)

1

Prepare the fracture site

  • partially remove the origins of the deltoid and the pectoralis major

2

Place the plate anteriorly

  • place a LCP or precontoured plate on the anterior aspect of the clavicle

3

Prepare screw placement

  • drill the clavicle from an anterior to posterior direction

4

Place screws

  • use the depth gauge to measure the appropriate length screw
  • a minimum of three screws should be placed in each major fragment
  • place interfragmentary screw
  • this screw greatly enhances the stability of the construct
H

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Deep closure

  • close the platysma with 0-vicryl

3

Superficial closure

  • close the subcutaneous tissue with 3-0 vicryl
  • close the skin with 3-0 monocryl

Patient Care

K

Preoperative H & P

1

Perform basic history and physical exam

  • identify medical co-morbidities that might impact surgical treatment

2

Order basic imaging studies

  • radiographs
  • AP
  • apical oblique

3

Perform operative consent

  • describe complications of surgery including
  • prominence of hardware
  • wound complications
  • infection
  • nonunion
L

Perioperative Inpatient Management

1

Discharge the patient appropriately

  • outpatient pt
  • remove dressing POD 2
  • pain meds
  • schedule follow up appointment in 2 weeks
M

Intermediate Evaluation and Management

1

Performs focused history and physical

  • determine the mechanism and date of the injury
  • concomitant and associated orthopaedic injuries
  • perform neurovascular exam
  • evaluate the soft tissue
  • look for tenting of the skin

2

Interprets basic imaging studies

  • AP
  • apical oblique

3

Prescribes nonoperative management

  • place in sling or figure of eight brace
  • patient to keep arm to side and limit activity for 4 to 6 weeks

4

Knowledge of surgical indications

  • open fracture
  • tenting of the skin
  • unstable Group II fractures (Type IIA, Type IIB, Type V)
  • subclavian artery or vein injury
  • floating shoulder (clavicle and scapula neck fracture)
  • symptomatic nonunion
  • posteriorly displaced Group III fractures
  • displaced group I (middle third) with >2cm shortening

5

Post operative management

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • start shoulder exercises at 4-6 weeks
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • check radiographs for fracture consolidation
N

Advanced Evalaution and Management

1

Order appropriate imaging studies

O

Complex Patient Care

1

Comprehensive pre-op planning/alternatives

2

Modify and adjust post-op plan as needed

3

Understand how to avoid and prevent complications

4

Treat simple complications intraoperatively and postoperatively

 

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